A. Periodontal Disease
The two major diseases of the oral cavity are dental caries, a disease process by which cavities are produced in the tooth surface, and periodontal disease, a process in which the bone and soft tissues supporting the tooth are destroyed. Periodontal diseases are a very common occurrence affecting, at a conservative estimate, between 70-90% of the world population and is the major cause of tooth loss in people over 35 years of age.
Periodontal disease is an all-inclusive term for a variety of clinical conditions that are forms of either gingivitis or periodontis. Gingivitis is an inflammation of the gingiva (or gums) that can be associated with poor oral hygiene and/or the hormonal state of the patient. It is believed that gingivitis, if untreated, will develop into periodontis. Periodontis is a bacterial disease in which the infection has progressed to involve the oral tissues which retain the teeth in the jawbone. Periodontis, if untreated, will eventually result in the loss of the affected tooth.
Although dental caries may be effectively treated with a combination of proper hygiene and fluoride, periodontal disease is often more refractile to treatment. This difference in amenability to treatment reflects the markedly different environments of the oral and periodontal cavities. The oral cavity is essentially an aerobic environment, which is constantly perfused by saliva. In contrast, the periodontal microenvironment is more anaerobic and is perfused by a plasma filtrate, known as the "gingival crevice fluid." The growth of microorganisms within this microenvironment has been shown to be the cause of periodontal disease (Loe, et al., J. Periodontol. 36:177 (1965); Slots, Scand. J. Dent. Res., 85:247 (1977); Socransky, S.S., J. Periodontol. 48:497-504 (1977); Axelsson, P., et al., J. Clin. Periodon. 5:133-151 (1978)). Hence, the treatment of the disease is directed toward controlling this growth. As the periodontal disease becomes more established, the periodontal microenvironment becomes more anaerobic and the flow of gingival crevice fluid increases. An excellent review of periodontal disease, and the methods for its treatment, is provided by Goodson J.M. (In: Medical Applications of Controlled Release, Vol. II, Applications and Evaluation (Langer, R.S., et al., Eds.), CRC Press, Inc., Boca Raton, FL (1984), pp. 115-138), which reference is incorporated by reference herein.
Efforts to treat periodontal disease have been impeded by several factors. Because the site of the bacterial infection is largely inaccessible to agents present in the oral cavity, antimicrobial agents provided to the oral cavity are generally ineffective. The increased flow of gingival crevice fluid, which accompanies periodontal disease, has the effect of diluting and removing therapeutic agents placed within the periodontal crevice. Systemic administration of antibiotics has been shown to be a useful method of controlling the subgingival flora (Listgarten et al., J. Clin. Periodont. 5:246 (1978)), however discontinuation of therapy is often associated with the return of the potential pathogens to the pockets. Systemic administration, therefore, has had only variable success in treating periodontal disease (Genco, R.J., J. Periodontol. 52:545 (1981)). Long-term antibacterial therapy has been used, but the potential dangers associated with this form of treatment, which include the development of resistant strains and super-imposed infections, do not warrant its serious consideration. Antibacterial agents such as chlorhexidine and quaternary ammonium salts in the form of mouth rinses have proved to be successful in preventing periodontal disease (Loe et al., J. Periodont. Res. 5:78 (1970)). These agents, however, are unable to affect the subgingival flora when administered in this form as they do not penetrate into the pockets which are the result of the disease. Hence, they cannot be used in mouth rinses to treat an established periodontal disease.
Patient acceptance has significantly limited the utility of non-pharmacological treatments of periodontal disease. The most widely used non-pharmacological approach to date has been mechanical cleaning methods combined with surgery. Although this method has proved to be fairly successful in treating individuals, there is still a high recurrence rate. There is also the problem of motivating people to good oral hygiene habits that they will maintain throughout their lives.